Surgical Management of Medication-Related Osteonecrosis of the Jaw Patients Related to Dental Implants

Italian position paper (SIPMO-SICMF) on medication-related osteonecrosis of the jaw (MRONJ)

OBJECTIVE

This paper aims to describe the 2023 update position paper on MRONJ developed by the Italian Societies of Oral Pathology and Medicine (SIPMO) and of Maxillofacial Surgery (SICMF).

METHODS

This is the second update following the 2013 and 2020 Italian position papers by the Expert panel, which is a representation of the two scientific societies (SIPMO and SICMF). The paper is based on an extensive analysis of the available literature from January 2003 to February 2020, and the subsequent review of literature conducted between March 2020 and December 2022 to include all new relevant published papers to confirm or modify the previous set of recommendations.

RESULTS

This position paper highlights the main issues of MRONJ on risk estimates, disease definition, diagnostic pathway, individual risk assessment, and the fundamental role of imaging in the diagnosis, classification, and management of MRONJ.

CONCLUSION

The Expert Panel confirmed the MRONJ definition, the diagnostic work-up, the clinical-radiological staging system and the prophylactic drug holiday, as recognized by SIPMO-SICMF; while, it presented novel indications regarding the categories at risk of MRONJ, the prevention strategies, and the treatment strategies associated with the therapeutic drug holiday.

Clinical and radiologic treatment outcomes of implant presence tirggered-MRONJ: Systematic review of literature

BACKGROUND

The present systematic review evaluated clinical and radiographic features and treatment outcomes of peri-implantitis-induced medication-related osteonecrosis of the jaws (Pi-MRONJ).

MATERIALS AND METHODS

Literature search was performed in PubMed/MEDLINE, Cochrane CENTRAL, Web of Science, and Scopus databases. Studies reporting Pi-MRONJ were included. No time restrictions were applied.

RESULTS

In total, 571 articles were retrieved, and 24 articles were included in the final review. Study population consisted of 111 patients (70% pharmacologically treated for osteoporosis and 30% for oncologic disease). Pi-MRONJ was characterized by pain, bone exposure and suppuration, and involved a single implant in 55 cases, two implants in 37 cases, three implants in 10 cases, and more than four implants in nine cases. Most of the lesions were assigned Stage II and III. MRONJ developed on average 46.5 ± 33.2 months following implant placement. Sixty-one lesions were surgically treated with implant removal and debridement of the surrounding necrotic bone. Complete wound healing was observed in 85% of cases.

CONCLUSIONS

The presence of dental implants in patients treated with antiresorptive drugs should be considered as a potential risk factor for MRONJ onset. In cases of periimplantitis with delayed wound healing following nonsurgical therapy, the clinician should rule out the presence of Pi-MRONJ.

Effect of agents affecting bone homeostasis on short- and long-term implant failure

OBJECTIVES

To review the current evidence on the relationship between agents that affect bone homeostasis and dental implant failures.

MATERIALS AND METHODS

Electronic searches for bisphosphonates, denosumab, methotrexate, corticosteroids, romosozumab, sunitinib, and bevacizumab were performed using PubMed, MEDLINE (OVID), EMBASE (OVID), Cochrane Central Register of Controlled Trials (Cochrane Library), Cochrane Oral Health Group Trials Register (Cochrane Library) and Web of Science (Thomson Reuters). Manual searches were also conducted to complement the digital searches for recent issues.

RESULTS

Previous publications suggested that bisphosphonates do not compromise the survival of dental implants. However, one study documented an increased risk of implant failure in patients who had received high-dose of intravenous bisphosphonate therapy after implant rehabilitation. There has been an issue of MRONJ around implants in patients who have successfully received implant therapy before and after antiresorptive therapy, leading to late implant failure. Despite evidence on the detrimental effects of denosumab, methotrexate and corticosteroids on bone metabolism, their role in implant survival is not conclusive.

CONCLUSIONS

At present, there is insufficient evidence to establish a potential connection between agents that affects bone homeostasis and implant failure. However, some studies have reported negative results for implant therapy. In addition, implant-related sequestration in patients who received anti-resorptive therapy, despite of successful osseointegration, is also noticeable. Although limited studies are available at present, clinicians should still carefully consider the potential hazards and take appropriate precautions to minimize the risks associated with the medications and implant therapy.

Medication-Related Osteonecrosis: Why the Jawbone?

Medication-related osteonecrosis of the jaw (MRONJ) has emerged as a complication of anti-resorptive medications. Despite its low incidence rate, this problem has gained attention in recent years due to its devastating consequences and lack of preventive strategy. The fact that MRONJ incidence has been exclusive to the jawbones, despite the systemic effect of anti-resorptive medications, could be a starting point to unravel the multifactorial pathogenesis of this condition. This review aims to negotiate the question of why the jawbone is more susceptible to MRONJ than other skeletal sites. Approaching the problem from this perspective could provide new directions for the prevention of MRONJ and expand our understanding of the unique oral microenvironment.

Medication-Related Osteonecrosis of the Jaw Associated in a Patient Treated With Etanercept

ABSTRACT

Medication-related osteonecrosis of the jaws (MRONJ) is defined as a pathologic condition affecting the maxillary and mandibular bones arising subsequently to pharmacological treatment with antiresorptive and antiangiogenic drugs.In this case report, the occurrence of MRONJ is described in a 66-year-old female patient affected by rheumatoid arthritis and treated with Etanercept, a Tumor Necrosis Factor (TNF)-α inhibitor. The patient developed a mandibular MRONJ following the extraction of teeth 3.4 and 3.5. The patient was then treated with conservative surgery of the necrotic bone. At 12-month follow-up complete resolution was observed. According to the data presented, the evaluation of the effects of new immunosuppressive biological therapies on the oral cavity appears of utmost importance in preventing the development of MRONJ. Although the risk related to TNF-α inhibitors has not been quantified yet, the clinician should be aware of the potential adverse effects on the oral cavity.

Medication-Related Osteonecrosis of the Jaw—A Continuing Issue

Introduction: Medication-related osteonecrosis of the jaw (MRONJ) is a condition that is becoming more common in the everyday practice of both dental and maxillofacial surgeons. Materials and methods: This paper aims to provide a comprehensive and easy to read by clinicians presentation of comprehensive, accessible, and up-to-date data on MRONJ. The individual chapters focus on the etiology, epidemiology, diagnosis, prevention, treatment, and recurrence of MRONJ. Results and discussion: It has been observed over the years that among drugs that increase the risk of the disease, apart from bisphosphonates, angiogenesis inhibitors and anti-RANKL monoclonal antibodies should also be included. A thorough physical and subjective examination, periodic correction of dental prostheses, and an adequate preparation for even the simplest of procedures in the oral cavity area can prevent or minimize the risk of MRONJ. Conclusions: It is extremely difficult to treat once it occurs and oftentimes is a recurring problem that leads to a multitude of symptoms that gradually decrease the quality of a patient’s life.

Medication-related osteonecrosis and osteoradionecrosis of the jaws: Update and current management

Medication related osteonecrosis of the jaws (MRONJ) and osteoradionecrosis of the jaws (ORNJ) are two different diseases of quite similar appearance. MRONJ is mainly due to antiresorptive or antiangiogenic drug therapy and ORNJ to radiotherapy. The present work aimed at presenting and comparing the current knowledge on MRONJ and ORNJ. They both present as an exposure of necrotic bone and differ in some clinical or radiological characteristics, clinical course and mostly in treatment. They share similar risk factors. A tooth extraction is more frequently found as a triggering factor in MRONJ. The frequency of a maxillary localisation seems higher for MRONJ. On computed tomographic images, a periosteal reaction seems characteristic of MRONJ. More frequent pathological fractures seem to occur in ORNJ. It is mandatory, for ORNJ diagnosis, to exclude a residual or recurrent tumour using histological examination. Both MRONJ and ORNJ are challenging to treat and cannot be managed similarly. For both, it would still be worth to optimise awareness within the medical community, patients' oral hygiene and dental cares to improve their prevention and make their incidences decrease. Conservative therapy is more frequently achieved for MRONJ than ORNJ and surgical resection is more often performed for ORNJ. For both diseases, the last treatment possible in refractory cases is a surgical extensive resection with free flap reconstruction. A MRONJ classification is widely used today, whereas no consensus exists to date for ORNJ classification. We propose a classification that could play this role.